PCP pneumonia: 27 yo M with cough and fever

CC: 27 year old male with fever
 
HPI:
27 y.o. male who presents  with continued fevers at home MAXIMUM TEMPERATURE 103, cough,  pain with inspiration and recently being treated with Azithromycin and Avelox by his family physician.  He completed each course of antibiotics without improvement. He had a chest x-ray at an urgent care as been diagnosed with pneumonia 2 weeks ago.  Continues to have cough that is productive,  pain with inspiration and fevers at home.
During initial assessment, patient denied any history of immunosuppression, HIV, on chronic steroids.
Review of systems was remarkable for fevers, chills, fatigue and 20 lbs weight loss.
Physical Exam:
Vitals: HR 133 BP 117/82, temp 98.4, RR 18, 95% on RA
HEENT: No lymphadenopathy, evidence of thrush on exam
Respiratory:   Does appear in acute respiratory distress.  Lungs clear to auscultation bilaterally.  No wheezes rales or rhonchi

Rest of physical exam was unremarkable.

EKG   
Sinus tachycardia, no ST elevations or T-wave inversions. No signs of STEMI
 
CXR
Showed bilateral atypical pneumonia – similar to bat wing formation.
 
Of note, while being wheeled to xray, patient alerted xray tech that he had tested positive for HIV in an outpatient clinic 1 month ago, but had not alerted his family. Did not have confirmatory testing yet, did not know his CD4 counts or viral load.
 
Diagnosis:
Atypical Pneumonia, persumed PCP in setting of HIV. Patient was discussed with ID, he had blood cultures drawn, started on Broad spectrum antibiotics and Bactrim PO and was admitted to the hospital.
 
Teaching Points:
 
1. Unexplained fever, thrush and atypical pneumonia on CXR in what appears to be an otherwise healthy adult should prompt investigation for possible underlying immunosuppression. In our case, we were going to perform a rapid HIV screen, but patient had made our lives easier but disclosing his history.
2. PCP pneumonia is possible when CD4 count less than 200 and patients should be on bactrim prophylaxis. Follow-up on my patient determined that his CD4 count was 119.
3. Treatment of choice for PCP pneumonia is Bactrim
4. #1 cause of pneumonia in HIV and immunocompromised patients is still Strep Pneumonia. Be sure to consider treatment of typical pneumonias in patients with immunosupression.
5. If suspect PCP pneumonia and patient is hypoxic, obtain blood gas. If patient has SP02 less than 70 need treatment with steroids. All patients who require corticosteroids need to be admitted to the hospital because of the risk of progressive respiratory compromise.
6. Spontaneous Pneumothorax is a common complication of PCP pneumonia.
 
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